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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS o/ �� /— L CITY/ZIP C/I m <br /> CROSS STREET��-^�4 _A P N O O �`•/ PARCEL SIZE LAND USE APPLICATIONf#� �f(� <br /> OWNER NAME �C//.t�i G PHONE�3 O /�2- ` -�+L► ui <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> Y <br /> CONTRACTOR /� FT v 5/'S llelpjr PHO�Ny�E r L-7-7, <br /> CONTRACTOR ADDRESS Pa Yy 17? CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT / wss�Q� <br /> PHONE!' <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE <C-57 CI C-61 U D-09 El Other NUMBER���36 EXPIRATION DATE_��3 <br /> BILLING PARTY: I I OWNER 1,CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING,: I i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)1 Arsenic(4393) <br /> INTENDED USE omestic/Private D Irrigation/Agricultural a Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK >rNeW Well U Replacement Well ❑ Well Alteration/Modification U Other <br /> 1-1 Monitoring Well(s) #of wells U Soil Boring(s) #of borings ❑ Geotechnical_ #of borings <br /> EI Out-Of-Service Well ❑ Out-Of-Service Well Renewal CI Cross-Connection Repair <br /> >ew Pump Pump Replacement ❑ Pum Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,>eMud Rotary U Air Rotary ❑ Auger U Cable Tool D Push Point U Other <br /> Proposed Well Depth00 ft Excavation LZ in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched2-7) D Steel -Plastic U Stainless Steel 9 Other <br /> Grout Seal Depth c� ft U Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> 11 Bentonite(20%solids) U Other <br /> Grout Placement MethodPKOPumped 17 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By>i_4 Driller D Pump Contractor U Other <br /> U Concrete Pedestal UDimensionsConcrete Pedestal Width Length _ft Thick Christy Box ❑ Stove PipeLength _ft Thic�❑ Christy Box ❑ Stove Pipe <br /> PUMP '-fieSubmersibie❑ Turbine U Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUIV[48 14OU>R_#DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 95�3-7/697 <br /> SIGNED--JTITLE®w l /°- DATE <br /> O <br /> T <br /> 21 <br /> IQ <br /> O Q INC UNTY <br /> MEW AL <br /> DEPART ENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date L'f- Z3 Z94' Area Employee ID# <br /> Grout Inspection B L' ►7rrL Date SPECIAL Well Permit <br /> Pump Inspection By��. '.�t� Date WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receive Check#/ Amount Permit! <br /> Codes Info Cash Remitted Date vice Request# Invoice# Well ID# <br /> C7 50 157, 1 OP- O <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />